Steve Hemingway RMN, BA(Hons), MA, PGDE Senior Lecturer in Mental Health
Room HW1/15 Harold Wilson Building
School of Health and Human Sciences, University of Huddersfield,
HD1 3DH UK
Tel: +44(0)1484 471859
e-mail: [email protected]
Terence McCann RN, MA, PhD Professor of Nursing Research School of Nursing and Midwifery
Victoria University Level 3
CHRE Building - Sunshine Hospital PO Box 294
176 Furlong Road St Albans, Victoria 3021
Australia
Tel.: +61 (0)3 839 58141 Email: [email protected]
John Stephenson, PhD
Senior Lecturer, School of Human and Health Sciences,
Centre for Health and Social Care Research, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH
T: +44(0)1484 471513
E: [email protected] Bronwyn Roberts
Bronwyn Roberts RLDN, BA(Hons),MSc Senior Lecturer in Learning Disability
Room HW G/23 Harold Wilson Building
School of Health and Human Sciences, University of Huddersfield,
HD1 3DH UK
Mental health and learning disability nursing students’ perceptions of the usefulness of OSCE to assess their competence in medicine administration
ABSTRACT: The aim of this study was to evaluate mental health and learning disability nursing students’ perceptions of the usefulness of the Observed Structured Clinical Examination (OSCE) in assessing their administration of medicines competence. Learning Disability (n=24) and Mental Health (n=46) students from a single cohort were invited to evaluate their experience of the OSCE. A 10-item survey questionnaire was used, comprising open- and closed-response questions. 12 (50%) learning disability and 32 (69.6%) mental nursing students participated. The OSCE was rated highly compared to other theoretical assessments; it was also reported as clinically real and as a motivational learning strategy. However, it did not rate as well as clinical practice. Content analysis of written responses identified four themes: Benefits of OSCE; Suggestions to improve OSCE; Concern about lack of clinical reality of OSCE; and OSCE induced stress. The themes, although repeating some of the positive statistical findings, showed participants were critical of the university setting as a place to conduct clinical assessment, highlighted OSCE related stress, and questioned the validity of OSCE as a real-world assessment. The OSCE has an important role in the development of student nurses’ administration of medicines skills. However, it may hinder their performance as a result of the stress of being assessed in a simulated environment.
INTRODUCTION
Medicine administration errors are preventable and have a negative impact on patient outcomes and experience, and create an economic burden to health services worldwide (Mutstata 2011; Nichols et al. 2008). In the United Kingdom (UK), for example, the National Patient Safety Agency (NPSA 2007) estimates that preventable harm from medicines costs in excess of £750 million each year in England alone. The Safety in Doses: medication safety in the NHS report states that medicines administration has a 5% error rate (Department of Health (DH), 2004), and in the mental health context it can harm 1-2% of admitted patients (Maidment et al. 2006). Some authors claim medicines-related activities are perhaps the highest risk management activity that most nurses undertake (Duxbury et al. 2010). Dealing with medication is a core nursing activity, with some estimates that 40% of nurses’ in-patient time is spent on medicines management-related activities (Armitage & Knapman 2003). Therefore, this core activity highlights the need for nurses to be competent in such interventions (Sulosaari et al. 2012).
gap (Dilles et al. 2011; Sulosaari et al. 2012). Another explanation is over-reliance on continuous assessment of medicines management competencies of student nurses by busy, under pressure clinical mentors across all nursing specialties (Bradshaw & Merriman 2008; Hunt 2011). It is unsurprising, therefore, that studies examining UK registered nurses administering medication have identified a failure to apply biological and pharmacological theory to learning disability (Dickens et al. 2006), medical-surgical (Nods & Newell 2009) and mental health settings (Turner et al. 2007); however, due to the small sample size of these studies their findings need to be treated with caution. It is also important to note that there are other explanations for nurses’ shortcomings in administering medication such as environmental distractions and inadequate medication documentation (Hemingway et al. 2011; Armitage & Knapman 2003). Moreover, it can be surmised that nursing students need adequate preparation for the role of administering medication.
In the UK, a four-step pathway to gaining competence in medicine management was developed by a university and a mental health trust for mental health and learning disability nursing students (Hemingway et al. 2010) (Figure 1). In Step 1, students are given a thorough grounding in psychopharmacology. In Step 2, their administration of medicine competence is assessed in a simulated assessment using an Observed Structured Clinical Examination (OSCE), in the university’s nursing skills laboratories, while their oral and intramuscular administration competence is assessed in clinical practice. If the now registered nurse is to proceed to build competence and confidence in all aspects of medicine management then an appropriate postgraduate course that furthers knowledge and expertise is the next step (Stage 3). Finally, if the mental health nurse is to make the transition to prescribing medicines (Stage 4), then the suggested stepped approach in Figure 1 can support development along a career-defined pathway.
2006). It has been claimed to be the ‘Gold Standard’ of clinical assessment (Bartflay et al. 2004; Wass et al. 2001), and can be used to simulate real-world clinical interventions and assess students safely in a controlled environment (Major 2007; Meecham et al. 2011; Selim et al. 2012; Watson et al. 2002). The OSCE has also been recognized as a major contributor to the improvement of clinical skill performance of graduate (Rushforth 2006; Mitchell et al 2008) and undergraduate student nurses (Meecham et al. 2011;Godson et al. 2007;). It can be used formatively, when linked to preparation for clinical placements (Anderson & Stickley 2002; Godson et al. 2007), or summatively, as a stand-alone assessment of undergraduate or postgraduate nursing programmes (Selim et al. 2012; Walsh et al. 2011). Simulation stations are utilised to assess students’ practical skills and knowledge. Compared to the potential bias of assessment of actual clinical practice, the OSCE has demonstrated reliability and validity (McNaughton et al. 2008; Selim et al. 2012; Walsh et al. 2011), motivates students to learn (Godson et al. 2007; Rushforth 2006), and gives prominence to acquiring mastery of practical skills as a major contributor to becoming a competent nurse (Mitchell et al. 2008; Watson et al. 2002). Criticisms of the OSCE include it being resource-intensive to operate (McNaughton et al. 2008; Walsh et al. 2011), the examination stress it produces may negate students’ performance compared to observation in practice (Furlong et al. 2005; Rushforth 2006), and that it does not truly reflect clinical reality (Mitchell et al. 2008).
Recent studies have shown how use of the OSCE can improve medical-surgical nursing students’ drug administration and applied pharmacology abilities (Meechan et al. 2011). Simulated skills sessions have also been identified as important to teach drug administration skills in preparation for clinical placements (Godson et al. 2007). Additionally, computer- and practice-based assessment approaches have been compared in the assessment of nursing students’ numeracy skills for medication dosage and calculations at the point of registration (Coben et al. 2010).
major stated benefit (Selim et al. 2012). It has been used in a variety of skills-based assessments, including interpersonal (Anderson & Stickley 2002), physical health (Jones et al. 2010), assessing skills when working with patients who misuse drugs (Baez et al. 2004), and assessing advanced practice psychiatric nursing skills in interviewing, assessing and diagnosing service users with mental health problems (Robbins et al. 2008). For learning disability nursing students, OSCE studies are limited to studies that include students from all fields of nursing; for example, their experiences of learning blood pressure measurement (Baillie & Curzo 2009).
Overall, no evaluation of learning disability and mental health nursing students’ administration of medicine competency, using an OSCE, has been published. Therefore, ascertaining students’ perceptions of the usefulness of OSCE in this situation could enhance nursing knowledge by contributing to the development of a more rigorous and reliable form of assessment of competence in the administration of medicines in pre-registration nursing and learning disability students.
Aim
The overall purpose of the study was to evaluate mental health and learning disability nursing students’ perceptions of the usefulness of OSCE, as a form of simulated learning, to assess their competence in administration of psychotropic medicines. Specific aims were to: (i) Understand the contribution of OSCEs in the preparation of the students in medicines
management.
(ii) Compare OSCE with other activities the students have experienced to help them develop their medication management role.
(iii) Ascertain the students’ rating of OSCE as a credible method of clinical assessment. **Insert Figure 1 about here**
MATERIALS AND METHODS Settings and participants
participate in the study. Data collection took place during the students’ final day in the University, prior to the completion of their course. They had completed all course-related assessments and were aware of the results. In order to minimise the likelihood of research-related stress occurring around the time they completed the actual OSCE, the final day of their course was chosen for data collection in the study. Because students were recruited from the school in which some of the researchers were employed, importance was placed on voluntary participation and anonymity, consistent with the approach stipulated by Clark & McCann (2005). While the researcher was absent from the classroom, students were asked to place the questionnaire (completed or uncompleted) in a box which, which was then sealed. Consent was assumed if students completed the questionnaire.
Procedure
Clinicians, who were active clinical mentors for students, collaborated with university academics to write OSCE scenarios. An answer guide was also developed, and before the OSCE took place all assessors (academics and clinicians) received a briefing to increase inter-rater reliability.
OSCE consisted of two assessment stations, which each student completed in the following order: (i) A written case scenario, which included reference to commonly prescribed medications (psychotropic and physical health) for an adult or older age patient. The student had 20 minutes to answer 6 questions related to the case scenario, and the answers to the questions could be located in the British National Formulary (2012). (ii) In the clinical skills laboratory, the student administered medication to a simulated patient as a follow-up to the written case scenario.
Data collection
compared to other assessments), ranging from least (1) to most (10) effective. Four items sought socio-demographic information.
The questionnaire was developed from a review of literature, about the value of OSCE in pre-registration nursing courses, and contributions from experienced nurse academics and registered nurses. It was then piloted within the mental health and learning disability nursing division at the University to determine the validity of its content. In order to increase its discriminant validity, advice was sought from a statistician (JS) to assess the questionnaire scoring format.
Data analysis
Quantitative data were analysed using SPSS (Version 18.0). Socio-demographic characteristics of participants were summarised using descriptive statistics, means and standard deviations (SD). The effectiveness of pharmacology education strategies was assessed using general linear models to determine significant differences between mean scores of individual strategies, and to identify socio-demographic factors that may significantly affect overall strategy mean scores. Cluster analysis techniques were used to determine effective groupings of these strategies. Descriptive and inferential analyses were also undertaken to determine associations between responses to questions relating to the clinical relevance and motivational value of OSCEs, and with confidence levels in the competent and safe administration of medication.
RESULTS
Socio-demographic characteristics of participants
Thirty-two mental health and 12 learning disability nursing students consented to participate, equivalent to a response rate of 69.6% and 50% respectively. Mental health students comprised 72.3% of respondents, while learning disability students comprised 27.3% of participants. Of the total sample, 24 (71%) were female and 10 (29%) were male representing the approximate. equivalent to the gender distribution on the course. Respondents were approximately equally split between those aged 18-25 years (n=16, 36.4%), those aged 26-35 years (n=13, 29.5%), and those aged 36-45 years (n=15, 34.1%). The median length of time respondents had worked previously in mental health care, as healthcare assistants, was 7-10 years (range 3 to 15 years).
Statistical analysis
A regression analysis was undertaken to identify socio-demographic factors affecting the overall mean score of the effectiveness of educational strategies for enhancing medication administration skills. Controlling for other demographic factors, only gender was found to significantly influence the mean score (p=0.035), with males showing a slightly less favourable view of strategies to assess medication administration competence in general than females (mean female rating 8.34; mean male rating 7.38). Female scores were also less variable than male scores. No significant differences in OSCE rating between males and females were found (p=0.862), although males scored OSCE slightly lower than females (mean female rating 8.41; mean male rating 8.25). The mean marks and Standard Deviations (SDs) awarded to each strategy, for males and females separately and for all respondents, are given in Table 1.
**Insert Table 1 about here**
pharmacology workbook and, to a lesser extent, UK Nursing and Midwifery Council competencies, were rated as less effective and formed a second cluster. Medicines administration was not clustered with other methods.
**Insert Figure 2 about here**
A further question asked respondents to assess the effectiveness of various strategies in contributing towards safe medicines practice. The findings showed that clinically-based mentor assessment was ranked highest by students. Mean (SD) scores (out of 10) are given in Table 2.
**Insert Table 2 about here**
A second regression analysis was undertaken to identify socio-demographic factors significantly affecting overall mean score. In this model, no predictors were found to be statistically associated with the outcome measure. A cluster analysis (Figure 3) indicated observation and self-taught assessment strategies formed a single cluster, with no other obvious groupings.
Insert Figure 3 about here**
Further questions elicited students’ opinion about whether OSCE clinical scenarios were as real-life as possible, and to ascertain if there was agreement with the statement that OSCE motivated and facilitated student learning. As the responses to both these questions was positive, a cross-tabulation of these responses revealed a strong association between perceptions of OSCE as a clinically real tool and perceptions of OSCE as a tool that motivates student learning (Table 3).
**Insert Table 3 about here**
motivates student learning (Z=0.447; p=0.655). The level of agreement between the two facets of the OSCE appears good.
The final closed question was concerned with students’ confidence levels in safe administration of medication. Of 43 responses, 29 reported themselves as “very confident” (67.4%), and 14 as “confident” (32.6%), while no respondents reported themselves as having “no confidence” in administering medication.
Qualitative Results
From the content analysis, statements were analysed and then abstracted into four categories: Benefits of OSCE; Suggestions to improve OSCE; Concern about lack of clinical reality of OSCE; and OSCE induced stress.
Benefits of OSCE
The involvement of clinical staff, who acted as assessors, was reported favourably as it made the assessment more relevant to their field discipline: “Particularly enjoyed OSCEs; good feedback from qualified staff, and appropriate to employment”.
Students also stated OSCE facilitated their skills and knowledge acquisition: “OSCEs are very useful on learning about the safe administration of medicine in the clinical area. They
help student nurses to learn practice effectively”.
OSCE had a motivating effect on student learning: “Makes you study in more depth”.
There was also comment that OSCE experience was used as a foundation to improve students’ performance in medication administration: “I ensured that feedback was adhered to and highlighted areas for improvement”.
The fact that OSCE provided variety in assessment was also highlighted favourably: “It is important to be assessed in a different way”.
Finally, even though OSCE appeared to be stressful it helped improved students’ confidence in medication administration: “This really helped my confidence, but at the time [I was being assessed using the OSCE] I was nervous”.
Student respondents highlighted issues they felt would improve the usefulness of OSCE. A university setting was questioned as the ideal place to conduct clinical assessment, and a suggestion was made about conducting the assessment in clinical settings: “Would like to see OSCEs undertaken on the ward by a qualified nurse who is unknown to you i.e. from
another ward”.
There was also comment about a preference to undertake a trial OSCE prior to the actual formal assessment using the approach: “Would have preferred to have a practice before the official one”.
“I would have preferred to have practice before OSCE”.
Another student claimed there was more value in using the OSCE as a formative rather than a summative mode of assessment: “I think the OSCE exam is really good experience and helped boost my confidence; however, I preferred the mock OSCE and feedback before the
exam as it helped me prepare for my exam better”.
Concern about lack of clinical reality of OSCE
Reliability and validity has been highlighted as a major benefit of using OSCE. One way of evaluating the external validity of the approach is to assess its transferability to practice settings. Comments indicated concern about the lack of clinical reality of OSCE and the fact that it may be better suited to being used in actual clinical settings: “OSCEs are designed to be real; however, they always have a fake feeling. I found it easier to be assessed on
placement”.
“OSCEs are as clinically real as possible within a university setting. However, OSCEs may
be more successful within a clinical setting, i.e. placement”.
OSCE induced stress
“These are a good learning experiences; however, they are not real so are very nerve racking”;
Compared to administering medication in the clinical setting, where each student had one mentor assessing his/her performance, OSCE required at least two assessors: one for assessment purposes, and one to ensure the examination conditions were maintained. A participant commented that the presence of an additional person contributed to her stress: “Too much pressure. [I] Think only one person should be in the room at one time”.
A final comment was made about the time constraints on students of the OSCE format and the adverse effect of this on their assessment performance: “Unrealistic timescale for [the OSCE] written exam. In [clinical] practice, I have always been told to take my time and double check everything to ensure no mistakes are made. Made an error on written part of
OSCE due to time running out and misreading the question”.
Even though there was acknowledgement of stress associated with undertaking OSCE, there was also recognition that it was a clinically realistic and beneficial form of assessment: “Yes, OSCEs are real as possible; even though they are nerve-racking they are beneficial”.
DISCUSSION
alternative form of assessment, and motivated them to learn in preparation for undertaking this novel form of assessment. However, the findings also highlighted various perceived shortcomings in OSCE.
The findings of the present study mirror other research findings; that OSCE motivates students to learn (Godson et al. 2007; Rushforth 2006), and is valued as a practically based learning and assessment strategy to assist them to develop their clinical skills (Mitchell et al. 2008; Watson et al. 2002). In the present study, the findings show OSCE is rated highly by students, in comparison to other teaching and learning strategies for medicines management, and these findings are similar to findings reported elsewhere (Hemingway et al. 2012a; Walsh et al. 2011). If mental health and learning disability student nurses are to receive appropriate preparation to administer medicines then, seemingly, OSCE can provide a rigorous alternative to other more theoretically based assessments such as examinations or written assignments (Hemingway et al. 2012b). If we accept the mantra that assessment can help motivate learning, then by making this assessment mode as near as possible to reality helps students learn and assimilate the skills and knowledge needed for clinical practice (Epstein 2007; Val Wass et al. 2001). Similarly, if OSCE reflects approximately what happens in practice, and enables students to assimilate knowledge and develop skills in order to pass the assessment, it can make a significant contribution to the acquisition of their competence in medicines administration (Hemingway et al. 2010, Meecham et al. 2011). The findings of the current study show OSCE used with mental health and learning disability nursing students is rated as highly as that evaluating its use in other nursing specialisms (Godson et al. 2007; Meecham et al. 2011).
This stress has been highlighted elsewhere but has not found to be more stressful than other forms of assessment (Brand, & Schoonheim-Klein2009; Furlong et al. 2005). Ways of helping to minimise OSCE-related stress include ensuring students receive thorough preparation in the operation of the assessment, and giving them an opportunity to undertake an initial trial OSCE and to receive feedback from assessors.
Findings from the content analysis of written responses indicated OSCE was criticised for not truly reflecting clinical reality, a shortcoming also reported by Mitchell et al. (2009). Even though OSCE was rated highly by students, its limited ability to reflect clinical reality, in turn, negated its external validity as a form of assessment. This perceived shortcoming might be attributable, in part; to the limited preparation some student participants claimed they received to undertake this assessment. If students value the knowledge and skills they acquire in order to successfully pass assessments and see its transferability to practice, this can increase their overall satisfaction and motivation to learn (Kurz et al. 2009). Therefore, adequate preparation is critical to making OSCE a valid form of assessment (Mitchell et al. 2009; Rushworth 2006). It is also important to ensure the OSCE is as real-life as possible. Ways of doing this include ensuring experienced clinicians and service user representatives are involved in the development of case studies; scenarios are updated regularly to ensure the content is realistic and up-to-date; and service user representatives and/or professional actors, who have been well briefed, take part in the simulated patient sessions (Meecham et al. 2011; Mitchell et al. 2009).
Limitations
students from other UK universities and from countries operating comprehensive pre-registration nursing curricula.
CONCLUSION
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